A Vignette from Psychiatry

I didn’t make it to rounds with the rest of my team because I was occupied with another one of our patients who was being assessed by the neurology consultant to be cleared to undergo electroconvulsive therapy. The spring sun shone bright through our large reinforced glass windows in the mood disorders unit at our psychiatric hospital, and lit up Hayley’s hair, as she patiently let me test her reflexes, check her strength, and assess her mental status.

Hayley was with us because she had mentioned to her therapist that she had a daydream the other day about stabbing herself in the neck with her pencil. In person, you would have never guessed that about her in a million years. She was young, frank, and friendly, and her soft cherubic face belied the fact that she was actually in her early twenties. Her troubles had begun when she was only eight years old. She had elected to undergo ECT shock therapy because she had failed over eleven different antidepressants over the course of as many years, and she’d had enough. But somewhere in her record is a mention of a possible cerebrovascular malformation, so we needed the neurologist’s expert opinion to deem her safe for the procedure.

I test her ‘fund of knowledge’. “Who is the president of the United States?”

“Obama.” The neurologist watches us.

Next I test her ‘attention’. “List the days of the week going backwards from Sunday.”

Hayley and I are the same age but she is a half a foot shorter than me. When she catches me staring at her intently, she grows shy and bites her thumb. The collar of her shirt is chewed up, either from frequent washes in the laundry or from anxious biting, but I don’t ask her which. She is thin, very thin. A primary care note from just the previous year said that Hayley was weighed at over 190 pounds, which considering her five-foot frame, meant definitively that she was ‘well-nourished’ and ‘couldn’t have an eating disorder’. Now Hayley weighs just over 110 pounds, but not to the point where you could count her ribs. She’d had broccoli for dinner the previous night.

“I want to be under 100 and they’re trying to get me to eat even more!” she says, laughing.

“What frustrates you?” I ask.

The answer is on her lips. “That I’ll get out of here, and be good for a few days, and then I’ll fuck up again. I’m always fucking up.”

Hayley has a sheaf of paperwork with her. She spends a lot of time in the activity room, coloring and she’s saved her art. Her favorite materials are crayons and watercolor. Hayley’s quite popular with the other residents because she’s always down to do anything. She loves going on walks with the mental health specialist at 2pm every day. Her mother visits on the weekends.

Hayley says everything with a smile, or a little laugh. Maybe she wants me to like her, which I already do. Maybe she wants to gloss over the ugly parts of her presentation, because she wants me to like her. Or maybe it’s just a nervous tic and I’m overthinking it.

The neurology attending takes issue with my tests of Hayley’s cerebellar function. I hadn’t asked her to slide her left heel down her right shin and vice versa, so he instructs her to do it. Then we test her gait, have her walk on her tippy toes and then her heels, and finally we ask her to close her eyes and stand very still, pushing her slightly to see if she can correct herself. If she falls, we would catch her.

And then we get down to the biology of it. I have a list of her current medications, and the neurologist and I confer about which drugs would lower the seizure threshold. Hayley is playing with her fingers now, her feet up under her, and she’s not a part of this conversation anymore.

“Is it okay if I talk to the student now, as part of some teaching points?” the neurologist asks Hayley. It’s the polite thing to do. She nods.

“There’s never been a randomized controlled study for the outcomes of ECT on people with cerebrovascular malformations,” he tells me. “But the literature of case reports suggests that it is safe, provided that the blood pressure is controlled under anesthesia. What did you think of the exam?”

“I thought it was fine,” I say. “Non-focal.” I look at Hayley and smile. “You passed with flying colors.”

“Right. I agree,” he says. “Remember that she couldn’t tell you how many dollars are in 9 quarters, but that’s okay. We’ll give her a pass for that one.”

“Will I be getting it today?” Hayley asks.

“Very likely, probably after noon.”

She can’t eat until after her procedure, but Hayley doesn’t mind. She gathers up her things, and leaves to go take a nap in her room. She wasn’t hungry anyway.

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